The Comprehensive AIDS Resources Emergency (CARE) Act: A Side-by-Side Comparison of Current Law and Reauthorization Proposals 2006 er mb e nov The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act: A Side-by-Side Comparison of Current Law and Reauthorization Proposals (as of November 1, 2006)

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, the nation’s largest HIV specific federal grant program and a critical source of care and treatment for people living with HIV/AIDS in the , was due to be reauthorized by the for the third time by the end of FY 2005. However, Congress has not yet acted to reauthorize the CARE Act, and the program’s authority has been extended under current law while Reauthorization discussions continue. The White House released principles for Reauthorization in July of 2005. A bipartisan Senate bill, The Ryan White HIV/AIDS Treatment Modernization Act of 2006, was passed by the Senate HELP Committee in May 2006. In September, the House passed a modified version of the bill, which may be considered by the Senate when Congress reconvenes in November.

The CARE Act is complex and understanding all of its provisions under current law, let alone some of the changes being considered by the Congress, is a challenging task. The following table, prepared by the Kaiser Family Foundation, provides a side-by-side comparison of current law to key provisions in the Administration’s reauthorization principles and The Ryan White HIV/AIDS Treatment Modernization Act of 2006. An earlier version of this side-by-side is available on the Kaiser Family Foundation website at http://www.kff.org/hivaids/7531.cfm.

Key Documents Used and Other Suggested Resources: Ryan White Comprehensive AIDS Resources Emergency Act of 1990, Pub. L. no. 101-381. Ryan White CARE Act Amendments of 1996, Pub. L. no. 104-146. Ryan White CARE Act Amendments of 2000, Pub. L. no. 106-345. United States Department of Health and Human Services, “Ryan White Care Act Reauthorization Principles”, Press Release; July 27, 2005: www.hhs.gov/news/press/2005pres/ryanwhite.html. U.S. Senate. 109th Congress, 2nd Session. S.2823. Ryan White HIV/AIDS Treatment Modernization Act of 2006. [introduced 17 May 2006 by Senators Enzi (R-WY), Kennedy (D-MA), Burr (R-NC), DeWine (R-OH), Frist (R-TN), and Hatch (R-UT)]. U.S. House. 109th Congress, 2nd Session. H.R. 6143. Ryan White HIV/AIDS Treatment Modernization Act of 2006. [introduced 21 September 2006 by Representatives Bono (R-CA), Barton (R-TX), Buyer (R-IN), Deal (R-GA), Gillmor (R-OH), Myrick (R-NC), Norwood (R-GA), Pitts (R-PA), Radanovich (R-CA), Terry (R-NE), and Upton (R-MI)]. Congressional Research Service, “Side by Side Analysis of The Ryan White HIV/AIDS Treatment Modernization Act of 2006”, Memo to Senate HELP Committee From Paulette C. Morgan and Judith A. Johnson; May 23, 2006. Congressional Research Service “The Ryan White CARE Act: a Side-by-Side Comparison of H.R. 6143 and Current Law”, Judith A. Johnson and Paulette C. Morgan; RL33671; September 26, 2006. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau website: http://hab.hrsa.gov/. National Alliance of State and Territorial AIDS Directors, Ryan White Reauthorization Information: www.nastad.org/Programs/HIVCareAndTreatment/RWReauthorizationInfo.aspx.

Key Dates in Ryan White CARE Act Reauthorization 1990, August 18: First passed; first funds awarded in FY 1991 1996, May 20: Reauthorized with Amendments 2000, October 20: Reauthorized with Amendments 2005, July 27: White House releases Principles 2005, September 30: Reauthorization expires 2006, May 17: Senate HELP Committee introduces and passes reauthorization bill 2006, September 21: House introduces reauthorization bill; passes on September 28.

Prepared by researchers at the Kaiser Family Foundation. Input provided by the National Alliance of State and Territorial AIDS Directors.

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Current Law: Administration’s Principles House Bill: H.R.6143 The Ryan White CARE Act of 1990 [P.L. 101-381] Introduced: Introduced: & Amendments of 1996 [P.L. 104-146] and 2000 July 27, 2005 September 21, 2006 [P.L. 106-345] Passed, September 28, 2006 Title Ryan White Comprehensive AIDS Ryan White Care Act Ryan White HIV/AIDS Treatment Modernization Act of 2006 Resources Emergency Act of 1990 Reauthorization Principles Purpose “To provide emergency assistance to localities that “Focus Federal resources on “…to revise and extend the program for providing life-saving care for those are disproportionately affected by the Human life-extending care; ensuring with HIV/AIDS” Immunodeficiency Virus epidemic and to make flexibility by targeting direct financial assistance available to states to resources to address areas of provide for the development, organization, greatest need; and achieving coordination and operation of more effective and results.” cost efficient systems for the delivery of essential services to individuals and families with HIV disease in urban and rural areas.” Structure The Care Act is structured around grant streams Overall Title structure not Overall Title structure maintained but further sub-divided and/or other that provide funding to cities, states, providers, and addressed changes to existing sub-components as follows: community organizations (as well as some other entities). There are five titles with subcomponents: Title I Planning Councils Title I: Now divided into 2 subparts Part A (Title I): Emergency Relief to Eligible would no longer be mandatory • Subpart 1 = EMAs (eligibility redefined; see eligibility) Metropolitan Areas (EMAs). Planning Councils and no longer required to set • Subpart 2 = TGAs, a new program for “transitional grant areas.” must be established; Planning Councils set priorities for spending. Metropolitan areas eligible as TGAs were previously eligible as Title II ECs priorities for spending. Establishment of Planning and “grandfathered” EMAs. Part B (Title II): HIV Care Grants to States, Council at discretion of Mayor. • Planning Council not mandatory for TGAs (unless a TGA was an EMA in including: Title II Base; AIDS Drug Assistance FY 2006). Program (ADAP); ADAP Supplemental Drug Treatment Grant (ADAP Supplemental); Title II: Emerging Community Supplemental Grant • New Title II supplemental grant program for states: first funds “hold (EC). harmless” for Title II awards; second, funds states with a precipitous loss Part C (Title III): Early intervention, capacity in funding; and third funds grants to states based on demonstrated need building, and planning grants to providers and for supplemental assistance, as determined by the Secretary. other eligible organizations. Supplemental grant funds to be used for core medical services (see Part D (Title IV): Women, Infants, Children & Youth definition below). grants to providers • Title II EC eligibility narrowed, since subset of previously defined ECs now Part E: Emergency Response Employees become eligible under new Title I TGA. Part F: AIDS Education and Training Centers Part F: Dental Education, Training, Reimbursement Part E: grants for emergency response employees deleted; new provision Part F: Special Projects of National Significance added to address public health emergencies. (SPNS) Part F: Minority AIDS Initiative codified as permanent part of the CARE Act (HRSA component only; MAI also receives funding from other parts of HHS).

Page 2 Current Law: Administration’s Principles House Bill: H.R.6143 The Ryan White CARE Act of 1990 [P.L. 101-381] Introduced: Introduced: & Amendments of 1996 [P.L. 104-146] and 2000 July 27, 2005 September 21, 2006 [P.L. 106-345] Passed, September 28, 2006 Eligibility for Title I: EMAs defined as areas with 500,000 or more Not specified Changes to Titles I and II. Funding: population reporting cumulative total of more than Titles I and II 2,000 AIDS cases for most recent 5 year period. Title I: Metropolitan area population size and disease burden eligibility Title II Base: all states, territories, associated thresholds changed. jurisdictions. Those with 1% or more of reported • Population: lowered to 50,000 or more. AIDS cases during most recent 2-year period must • Disease burden specified by subpart: provide non-federal matching funds according to Subpart 1 EMAs: cumulative total of more than 2,000 AIDS cases during escalated matching rate (based on number of most recent 5-year period (same as current law EMA eligibility) years at or above 1% threshold). Subpart 2 TGAs: cumulative total of 1,000-1,999 AIDS cases during most Title II ADAP: all states, territories, associated recent 5-year period (previously eligible under Title II EC grant). jurisdictions. Title II ADAP Supplemental: for states with “severe Title II: EC and ADAP Supplemental eligibility changes. need” as determined by the Secretary, and to • ADAP Supplemental: adds requirement that states cannot have more than include consideration of eligibility standards, 2 percent in unobligated funds; changes part of severe need criteria from formulary composition, and the number of “number of individuals at or below 200% FPL” to “unanticipated increase individuals at or below 200 percent of the federal in individuals eligible for ADAP”; no longer ties to January 2000 criteria; poverty level (FPL). States must match $1 in non- State matching requirement can be waived under certain circumstances. federal funds for every $4 in federal funds. States • ECs: disease burden eligibility changed to cumulative total of 500-999 cannot impose eligibility requirements that are AIDS cases during most recent 5-year period (areas previously eligible as more restrictive than those in place as of January ECs because they had 1,000-1,999 cases now eligible under Title I 1, 2000. TGAs). States would have to agree that grant would be used to provide Title II ECs: metropolitan areas not eligible for funds to ECs separately from other Title II funds provided to ECs. funding under Title I and with cumulative total of 500-1,999 AIDS cases in most recent 5-year period (In FY 2007 eligibility for ECs switch to HIV cases only). Funding Funding distributed by formula, supplemental Calls for changes to Title II Calls for changes in Title I and II formula weights and funding distribution Distribution for (competitive) grant awards, and set-asides Base Formula to eliminate must be based on use of living HIV/AIDS cases from names-based reporting Titles I and II depending on Title and subcomponent. “double counting” of HIV/AIDS states only unless exemption is received (see next section). Title I: 50% by formula, 50% supplemental. Formula cases between metropolitan = EMA’s share of total number of estimated living areas and states. Title I: More weight given to formula as follows: 2/3 formula, 1/3 AIDS cases (ELCs*) in all EMAs. Supplemental supplemental, applies to EMAs and TGAs. based on “severe need” Calls for Secretary of HHS to • Formula = EMA’s (or TGA’s) share of living HIV/AIDS cases in all EMAs Title II Base: 100% formula. develop "severity of need" for (or TGAs). Formula = [(80%) x (state’s share of all ELCs)] + core services index (SNCSI) • Supplemental: first funds hold harmless for EMA awards; second, funds [(20%) x (state’s share of all ELCs outside of to be used to determine EMAs with a precipitous loss in funding; and third, funds grants to EMAs EMAs)] formula allocations to states based on “demonstrated need” as measured on “objective and quantified Title II ADAP: 100% formula. Same formula as Title and EMAs. basis” to be determined by the Secretary of HHS. II Base • Supplemental distributed to EMAs and TGAs through one mechanism; Title II ADAP Supplemental: 3% of ADAP earmark Secretary has discretion on allocating supplemental between them. set-aside for Supplemental and distributed to eligible states who apply for funding. Title II Base: More weight given to areas outside of EMAs/TGAs and to Title II EC: Set-aside of Title II Base and distributed states with no EMAs/TGAs. Changes 80/20 formula to 75/20/5 by 100% formula. Formula = EC’s share of total • Formula = [(75%) x (state’s share of nation’s HIV/AIDS cases)] + [(20%) x number of reported AIDS cases in all ECs in most (state’s share of HIV/AIDS cases outside of EMAs and TGAs)] + [(5%) x recent 5 year period. (state’s share of HIV/AIDS cases from states without any EMAs or TGAs)] • Severity of Need Index could replace formula as early as FY 2011; *ELCs are determined by applying defined survival required to be used by FY 2013. weights by year to the cumulative number of AIDS cases reported over the preceding 10 year period. Title II ADAP Supplemental: set-aside increased from 3% to 5% of ADAP earmark.

Title II EC: Set-side authorized at $5 million of base. Formula = EC’s living HIV/AIDS cases as share of all living HIV/AIDS cases in ECs nationwide. Page 3 Current Law: Administration’s Principles House Bill: H.R.6143 The Ryan White CARE Act of 1990 [P.L. 101-381] Introduced: Introduced: & Amendments of 1996 [P.L. 104-146] and 2000 July 27, 2005 September 21, 2006 [P.L. 106-345] Passed, September 28, 2006 Use of HIV cases Uses estimated living AIDS cases. Affirms current law (switch to Affirms current law (switch to HIV cases by FY 2007). Specifies that formula in Funding Care Act Amendments of 2000 required Secretary HIV cases by FY 2007). will use living HIV/AIDS cases from names-based reporting states only, after Formulas for of HHS to determine no later than July 1, 2004 being reported to and confirmed by the Centers for Disease Control and Titles I and II whether data on cases of HIV disease from all Prevention (CDC). A second “track” of states and EMAs/TGAs that do not eligible areas were sufficiently accurate and reliable have certified names-based HIV cases with the CDC, but use code-based for use in funding distribution formulae (to replace systems, will have their code-based HIV cases used for funding distribution use of AIDS cases). If not by then, must go into purposes after an adjustment (described below). effect by FY 2007 (note: it was determined that HIV cases were not sufficiently accurate and reliable by Transition Plan: specifies 4-year transition plan through FY 2010, for states July 2004, so the latter deadline of FY 2007 is in without established HIV names-based surveillance systems if they submit effect). transition plan by October 1, 2006 (NOTE: All states have submitted a transition plan to CDC).

For states (and jurisdictions within) with exemptions that have code-based HIV reporting, their HIV counts provided to HRSA for purposes of funding distribution will be reduced by 5%. Grandfathering Grandfathering: Grandfathering: Grandfathering: and Hold Title I EMAs that were eligible in FY 1996 remain Not specified. Title I: Harmless eligible in subsequent years. • Subpart I: eligibility maintained in FY 2007 even if EMA does not meet Provisions Hold harmless: Subpart I or Subpart 2 eligibility and will be considered TGA. Eligibility Hold harmless: Calls for eliminating “hold would end if EMA fails to have cumulative total of 2,000 or more living Grandfathering: Title I EMAs are protected from funding losses for 5 harmless” for Title 1 AIDS cases in most recent 5-year period and a cumulative total of 3,000 protection from years using percentages of 98, 95, 92, 89, 85 of or more living AIDS cases in most recent year. loss of eligibility base year grant. Base year is the year previous to • Subpart 2: eligibility for TGAs maintained until fails to have at least 1,000- from year to year the loss in funding. 1,999 cases of AIDS during most recent 5-year period and 1,500 or more Title II Base and ADAP protected from funding living cases of AIDS as of most recent year. Hold harmless: losses for 5 years using percentages of 99, 98, 97, protection from 96, 95 of base year grant. FY 2000 was base year Hold Harmless: loss of funds due for most recent reauthorization. Title I: to changes in Subpart 1: for EMAs that were held harmless in FY 2006, extended for 3 formula funding years at 95% of the previous year’s award each year (after taking into distribution account new formula weights). amounts from Subpart 2: No hold harmless provision. year to year Title II: FY 2007-2009, 95% hold harmless; hold harmless eliminated after FY 2009 Core Medical No core set of medical services specified or tied to Yes. Yes. Services funding. At least 75% of funds for At least 75% of funds for Titles I-III must be spent on core medical services Titles I-IV must be spent on (including for co-occurring conditions) defined as including: core medical services outpatient and ambulatory health services; medications; pharmaceutical (services not specified) assistance; oral health care; early intervention services; health insurance premium and cost sharing assistance for low-income individuals; home health care; medical nutrition therapy; hospice services; home and community based health services; mental health services; substance abuse outpatient care; and medical case management, including treatment adherence services.

Requirement can be waived if there is no ADAP waiting list and core medical services are otherwise available to all eligible. Support Defined as outpatient and ambulatory support Defines support services as services needed by individuals with HIV/AIDS Services services (including case management), that to achieve medical outcomes (e.g., respite care; outreach; medical facilitate, enhance, support, or sustain the delivery, transportation; linguistic services, referrals for health care and support continuity, or benefits of health services for services). Medical outcomes defined as those outcomes affecting the HIV- individuals and families with HIV disease. related clinical status of an individual with HIV/AIDS.

Page 4 Current Law: Administration’s Principles House Bill: H.R.6143 The Ryan White CARE Act of 1990 [P.L. 101-381] Introduced: Introduced: & Amendments of 1996 [P.L. 104-146] and 2000 July 27, 2005 September 21, 2006 [P.L. 106-345] Passed, September 28, 2006 Minimum No formulary specified. Yes. Yes. Formulary for CARE Act states that the purpose of ADAPs is to: Requires Secretary of HHS to Requires Secretary of HHS to develop a list of core antiretroviral drugs, as ADAP “…provide therapeutics to treat HIV disease or develop a list of core ADAP specified by Clinical Practice Guidelines for Use of HIV/AIDS Drugs, and prevent the serious deterioration of health arising drugs to be prioritizing for drugs needed to manage symptoms associated with HIV. ADAPs are from HIV disease in eligible individuals, including funding. List based on Public required to provide all antiretrovirals. measures for the prevention and treatment of Health Service guidelines and opportunistic infections.” to include antiretrovirals and drugs needed for the treatment and prophylaxis of opportunistic diseases. Unspent Funds Formula grant fund amounts may be adjusted by Allows Secretary of HHS to If EMA does not obligate all of formula or supplemental funds within a year Secretary of HHS to reflect unspent or canceled redistribute unspent funds of award, funds must be returned. Waivers of cancellation of formula grant amounts from preceding year. Expiring funds return from Titles I and II to ADAPs balances may be requested. Formula grant would be reduced in subsequent to the Treasury. with the greatest need. year by amount of unobligated/canceled balance. Unspent funds will also be returned to the respective supplemental pot beginning with FY 2007 money. Expiring funds from years previous to FY 2007 will return to the Treasury.

Other SPNS – eligible entities are public and private HIV Testing: Requires states SPNS: eligible entities are those eligible for funding under Parts A-D only; entities. to implement routine voluntary new criteria for awards added. Funds will be used to develop a client-level HIV testing in public facilities data collection system. HIV Testing: any HIV testing conducted by a Title III and work with private grantee must be carried out in accordance with providers to achieve that HIV Testing: Pre-test counseling no longer mandated under Title III. Title III specified provisions concerning confidentiality, same end. grantees can test individuals after individual confirms test was voluntary. informed consent, counseling and testing, Adds requirement that individuals testing negative or positive must also regardless of whether funds used for testing are Hepatitis: Not specified. receive counseling information about Hepatitis A, B, and C transmission and funds appropriated under the CARE Act, including prevention and Hepatitis A and B vaccines. Deletes requirement that these the requirement that individuals have pre-test provisions apply regardless of whether funds used for testing are counseling and sign statement declaring that appropriated under the CARE Act. counseling occurred and testing was voluntary. Specifies type of counseling to be offered if Hepatitis: See above individuals test negative and positive, respectively.

Hepatitis: Not specified.

Page 5 Current Law: Administration’s Principles House Bill: H.R.6143 The Ryan White CARE Act of 1990 [P.L. 101-381] Introduced: Introduced: & Amendments of 1996 [P.L. 104-146] and 2000 July 27, 2005 September 21, 2006 [P.L. 106-345] Passed, September 28, 2006 Authorization of “…such sums as may be necessary...” Not specified. Title I: $604,000,000 for FY 2007, $626,300,000 for FY 2008, $649,500,000 Appropriations for FY 2009, $673,600,000 for FY 2010, and $698,500,000 for FY 2011; of SPNS: Authorized to be funded through a set-aside which: of no more than $25 million across the Titles. • For FY 2007, $458,310,000 reserved for EMAs and $145,690,000 Appropriations bills have directed that SPNS funded reserved for TGAs. Secretary determines amount in subsequent years. should come from PHS evaluation set-asides. Title II: $1,195,500,000 for FY 2007, $1,239,500,000 for FY 2008, $1,285,200,000 for FY 2009, $1,332,600,000 for FY 2010, and $1,381,700,000 for FY 2011; of which: • Title II ECs: $5 million reserved each FY • Title II Supplemental: 1/3 of new money reserved each FY • $10 million for partner notification each FY if appropriated

Title III: $218,600,000 for FY 2007, $226,700,000 for FY 2008, $235,100,000 for FY 2009, $243,800,000 for FY 2010, and $252,800,000 for FY 2011.

Title IV: $71,800,000 for each FY 2007-2011

Part F: AETCs: $34,700,000 for each FY 2007-2011

Part F: Dental: $13,000,000 for each FY 2007-2011

SPNS: Of amount appropriated under parts A-D, the greater of $20,000,000 or amount equal to 3 percent of such amount appropriated under each such part, but not to exceed $25,000,000

MAI: $131,200,000 for FY 2007, $135,100,000 for FY 2008, $139,100,000 for FY 2009, $143,200,000 for FY 2010, $147,500,000 for FY 2011.

Other: $30 million of funds appropriated to CDC would be made available each FY for early diagnosis grants to states until the funds are spent. $20 million is for grants to states that have voluntary opt-out testing of all pregnant women and mandatory testing of newborns; $10 million is for grants to states that have voluntary opt-out testing of clients at STD clinics and voluntary opt-out testing of clients at substance abuse treatment centers

Page 6 Additional copies of this publication (#7531-02) are available on the Kaiser Family Foundation’s website at www.kff.org.

The Kaiser Family Foundation is a non-profit, private operating foundation dedicated to providing information and analysis on health care issues to policymakers, the media, the health care community, and the general public. The Foundation is not associated with Kaiser Permanente or Kaiser Industries.

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